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DSM-V offers new criteria for personality disorders

The American Psychiatric Association is in the middle of a historical revision to its diagnostic "Bible", the Diagnostic and Statistical Manual of Mental Disorders (or DSM). Here's a look at the changing landscape of personality disorder diagnosis. Read More

Good work

I very much enjoyed this.

Sincerely,David

re: Good work

Thank you, David!

A Trashcan Category

The whole field of personality disorders is little more than a set of trashcan diagnoses. Particularly problematic is the borderline category. The "new" ideas behind this category are really not new at all. What the working group did was simply add more levels of specificity. The actual diagnostic criteria, although regrouped and to some extent reworded, are basically the same and as such, present the same problems. More specifically, aside from self-harm, there is little in the criteria that is not wide open to subjective interpretation by the psychiatrist. In other words, the criteria aren't meant to fit the patient; rather, the psychiatrist just makes whatever the patient confides to him/her fit the criteria so the diagnosis can be made. There's nothing even remotely empirical about it.

As well, even though there is some mention of looking at the patient's reported experience within his/her own culture, this rarely happens. The psychiatrist's interpretations are always tainted by his/her own cultural values and norms. That's the nature of interpretation. Also, psychiatrists rarely spend enough time with their patients to have any real sense of what their lives are actually like, and I highly suspect that the borderline diagnosis is often made simply so that the psychiatrist can avoid taking responsibility for his/her own counter-transference issues.

All in all, the borderline label has been overwhelmingly used pejoratively, and the number of patients whose lives have been permanently damaged by what Judith Herman calls "the sophisticated insult" should be a source of shame for the psychiatric profession. As I said, the whole category of personality disorders is just a trashcan, and as far as I'm concerned, that's where these "diagnoses" belong. Unfortunately, until psychiatry becomes more about helping patients live better lives than about bolstering up psychiatrists' egos and sense of authority, we're going to be stuck with this useless, harmful category. In the meantime, patients need to be forewarned that their Axis II diagnosis will most likely be from this category, that this label is going to stick to them like glue long after they've left treatment, and that it will negatively impact any treatment they seek in the future.

Here's hoping the APA will eventually wise up and start taking their ethical obligations to their patients seriously.

Easy to say, Anonymous . . .

Easy to say, Anonymous . . . until you get to know somebody with this type of personality! I've spent enough time around someone with this disorder to know that it's not a "trashcan diagnosis", but refers to a real and pervasive problem within the patient's worldview that translates into broadly dysfunctional interpersonal relationships.

Being able to identify this as a psychiatric category has been extremely helpful for me and many others who've lived with a personality-disordered person. Though I'm unable to comment on whether it also helps the person with the disorder, since I've not been in that particular position, I wholeheartedly reject the idea that the category is a phony diagnosis aimed at bolstering doctors' egos at patients' expense.

Wow! Those are some strong

Wow! Those are some strong feelings. I hate to be the one, but I'm one of those patients who is an actual Borderline. I fit the bill perfectly (it's kinda scary when I reflect back on it). If you were to meet me, and I gave you my life story would you believe me? Personally I could care less, but I was one of those few who was given every other diagnosis in the book except a personality disorder. When I was actually diagnosed it finally all made sense, and I was luckier than sin that my therapist was able to identify and treat me till the end. I do feel that it is sad when others are diagnosed into "trash can" disorders, but for the people that actually have these traumatic experiences and need to be given treatment for something, these disorders are there. To me and anyone with these disorders, These are not "trash can" disorders but I real life struggle.

thoughts on trashcans

Anon,
Forgive me but I feel I must ask - how would you define mental illness? I'm curious as to whether you have an alternate proposal to what the APA has laid out here. Not that your argument is invalid if you don't have a plan on hand, but I'm curious as to your thoughts.

Thanks!

re: trashcans

Great comments, Anonymous and Zac. Anonymous raises some great concerns above about the misuse of psychiatric diagnosis. Diagnosis is a tool, and like any tool, can be used well or poorly, for good or for ill. I hope to get to a follow-up post with a lot more thoughts about why diagnosis is important and some of its potential pitfalls.

I hope that the comments and conversation continue!

Re: Thoughts on Trashcans

Zac,

How would I define "mental illness"? At this point, I wouldn't even try. There is so much controversy over what constitutes mental illness that any definition is problematic. My objection to the personality disorders categories, however, isn't really based in any particular definition of mental illness. It's actually much simpler than that: they aren't categories that help the patient because they don't really diagnose anything. As such, they offer neither the patient nor the clinician any substantive foundation on which to build a treatment plan.

More specifically, the personality disorder categories are odd sorts of circular constructions. For example, look at a non-personality disorder condition like schizophrenia. There is an underlying condition that expresses itself through a specified range of observable symptoms. When a patient expresses at least some of these symptoms, the psychiatrist can diagnose (i.e. discover the underlying cause or nature of) the problem and can then either treat or at least manage the condition.

In personality disorders, the same does not hold true precisely because there is no specific underlying condition to be discovered. In essence, there is nothing to diagnose because that's not how the categories and their criteria are set up. The "observable phenomena" in a personality disorder are largely based on psychiatric interpretation of patient narrative and don't describe an underlying condition; rather, they create one. It's backwards. It's a matter of using interpretation to create the symptoms so that one can then create the disease.

Personality disorders are fundamentally empty categories, and as such, it's not too surprising that most of them have no particularly effective treatment. There isn't, after all, really anything to treat. All psychiatry can offer someone unlucky enough to get tagged with, say, something like a BPD label is behavior modification in the form of Dialectic Behavior Training, which doesn't help the patient so much as it just makes him/her easier for everyone else to be around. The underlying trauma likely responsible for the person's actions is never addressed because to do that, one would need a usable diagnosis like PTSD (and it's worth mentioning that while PTSD and BPD actually share a number of diagnostic criteria, PTSD recognizes and in fact, emphasizes a causal connection with the past, while BPD ignores it, which is largely why the latter is inherently tautological).

So, my plan would simply be to get rid of the personality disorder categories altogether because they are simply not useful except as a code for psychiatrists to warn each other off patients that may require more time and effort than they care to provide. In short, then, the personality disorders don't actually diagnose anything, they aren't useful to patients, and the stigma they carry with them frequently does a great deal of emotional damage to the patient. Thus, I say "get rid of them."

Given the APA's love of the multi-dimensional diagnosis model, though, I doubt this will happen anytime soon. After all, psychiatrists have to write something in the Axis II box. So, what I would propose is this: no patient should be given a diagnosis of a personality disorder unless 1) he/she is fully informed of the criteria of that disorder as it is written in the DSM, 2) he/she is fully informed of the evidence being used to establish the diagnosis, 3) he/she is given at least one week to research the impact and stigma of such a diagnosis, 4) he/she agrees IN WRITING that the psychiatrist's interpretation of the information the patient has provided is an accurate reflection of the patient's real, lived experience, and 5) he/she agrees IN WRITING to accept the diagnosis. In other words, psychiatrists can no longer just make these diagnoses without the patient's fully informed and written agreement. If the patient does not agree, the diagnosis cannot be made. Finally, services cannot be withheld or terminated if the patient refuses to accept the diagnosis.

Now, that's what I call "informed consent," and for empty, subjective categories like personality disorders, I think that's what is necessary. Psychiatrists use diagnoses of personality disorders secretively and in some cases, punitively, and given how damaging these labels can be in the long-run, patients need that level of protection.

As someone who has been stuck

As someone who has been stuck with said Borderline diagnosis, I say: THANK YOU, so much, for this. I was hoping against hope that the diagnosis of Complex PTSD (which would have absorbed a great number of "borderline" diagnoses) was going to be included in the new DSM-V, but it has yet to show up. Why can't they recognise that many Borderline traits are adaptive responses to trauma/problematic upbringings, rather than a fundamental flaw in one's personality? Considering that many consider the personality to be a "soul" of sorts, to be told that it's disordered (and apparently, in the new DSM, punished by being classed under the same diagnostic heading as a psychopath) is an incredible blow to one's sense of worth.

As someone who has been stuck

As someone who has been stuck with said Borderline diagnosis, I say: THANK YOU, so much, for this. I was hoping against hope that the diagnosis of Complex PTSD (which would have absorbed a great number of "borderline" diagnoses) was going to be included in the new DSM-V, but it has yet to show up. Why can't they recognise that many Borderline traits are adaptive responses to trauma/problematic upbringings, rather than a fundamental flaw in one's personality? Considering that many consider the personality to be a "soul" of sorts, to be told that it's disordered (and apparently, in the new DSM, punished by being classed under the same diagnostic heading as a psychopath) is an incredible blow to one's sense of worth.

Anonymous: I think the

Anonymous:

I think the proposed version of DSM-V advocates the elimination of Axis II:

"The subgroup has recommended that DSM-5 collapse Axes I, II, and III into one axis that contains all psychiatric and general medical diagnoses. This change would bring DSM-5 into greater harmony with the single-axis approach used by the international community in the World Health Organization’s (WHO) International Classification of Diseases (ICD)."

http://www.dsm5.org/ProposedRevisions/Pages/ClassificationIssuesUnderDis...

I agree, also, that personality disorders cannot be defined in a reductionist manner; hence, a logical, structural reading of personality disorder diagnoses would turn into circular logic and contradictory chaos. Linehan's description of BPD [1], which is deconstructive [2] in nature, shows that the BPD diagnosis is already falling apart once you start constructing it as a discrete cognitive structure.

[1] Linehan, Marsha M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

[2] http://en.wikipedia.org/wiki/Deconstruction

DSM new criteria

Hey Jared,
thank you for this, it's a really nice summary. In regard to the shift in definition of what a PD is, I wonder if we're not losing something by focusing on a disruption in adaptation to the exclusion of the individual's internal experience. I think the extent to which an individual feels they are part of the problem, so to speak, or are experiencing internal distress is an important part of diagnosis. Also, while there was a lot of overlap in the 10 PD types, I fear that we are now at risk of the pendulum swinging to far in the other direction and are missing important distinctions. For example, I imagine those previously considered 'schizoid' will now be labeled 'avoidant'. These two may present similarly but have very different underlying dynamics. Lets not interpret my choice of example :)
Hope you are well,
Meg

Very good information

Very good information

This was immense remarks towards the Personality disorder in DSMV as well as good information too. Congratulation

Best wishes,
Anil

Hmmm...introversion is pathological...ok...

This is likely a knee-jerk reaction, but, as a pronounced introvert who gets along quite well in the world relationally (and always has), I'm suspicious of classifying introversion as pathological for purposes of labelling someone personality-disordered (five traits, the other four of which are clearly pathological - introversion must be a "damaged/sick" trait as well, especially when pronounced, right?). Hmmmmm....probably need to research that a bit more.

Introversion

I too am concerned about including introversion under traits associated with PDs. If we are to consider introversion a trait that warrants investigation the counter and balancing trait of extraversion ought to be on the list for exploration. The assumption that extra version is a good thing and introversion not so good is ridiculous. My iPad even has a built in bias and prefers to separate extra from version, humm

Very helpful new concepts

As a lay person who has to live with personality disorder in the family, this new approach with less categories is better because most of the other disorders were extreme overlap anyway and the five disorders which remain are basic and easier to recognize and understand. Good work!

DSM-V proposed reductionist approach to Personality

I admire that Workgroups good intentions in bringing DMS-V personality diagnosis into line with research, but sadly, it is at the cost of the richly descriptive categories currently in use. We all know what is meant by Narcissitic PD and Histrionic PD, and the current differences between Schizoid and Avoidant PDs describe clear and important distinctions between the two. I am concerned that this new, well-meaning approach to ensure greater "empirical validity" means that personality will be conceptualized as 'numbers & scales', losing DSM's value in providing a rapidly digested shorthand for describing patient psychopathology and functioning.

Among my colleagues, there is widespread dismay at the proposed new Axis II system. Most believe that clinicians will continue to employ the 'old' personality classifications as descriptors in their narratives because of their rich tradition and ability to convey personality constellations in a way that is useful and understood by all (in effect, we will move forward with two diagnostic systems). While DSM has *gradually* evolved over the years, the proposed new Axis II of DSM-V represents a radical departure that may, if fact, be more empirically sound, but in practice, unwieldy and less useful to clinicians. The new system may be more elegant in its own way, but it does not speak to those of us using/doing diagnosis demanding clinical settings.

Clinician In Favor of Axis II Diagnosis

It's true that the underpinnings of Axis II diagnoses may not be perfectly objective, and also that people are damaged by wrong diagnoses, just as some people are damaged by drugs which can be useful but are used in the wrong way.

As a clinician who has been on the front lines however, the reality of something like axis II diagnoses is rather unavoidable, there are many, many people who are not "crazy" in terms of seeing that a chair is in front of them, not an elephant, etc.; but they misread social cues so badly, or, worse, are so extremely indifferent to others (Anti-Socials) that there is no better way currently to categorize them any more accurately.

As on commenter said, "Nice criticism" of Axis II from anonymous, but: "Where's your alternative?"

One of the origins of the Anti-Social personality diagnosis came from a book by Cleckly, called "The Mask of Sanity." In it he studied anti-socials, and saw that they saw what was around them, and weren't crazy in the colloquial sense-- they just didn't care about how they got their thrills.

Another layer of diagnosis was needed to explain them. The personality disorder layer.

There is room for improvement, but to make believe there's no such thing is just unrealistic.

'Another layer of diagnosis

'Another layer of diagnosis was needed to explain them. The personality disorder layer.'

Isn't this misapprehension at the heart of the problem? The philosophy of the DSM seems to rest on the assumption that to describe, to categorise, is to explain. It is disturbing to see someone who calls him/herself a clinician presenting such a fundamental error.

Broadly speaking, revising the DSM seems as much use as the proverbial Titanic deckchair arrangement. The whole concept of personality disorder is such a Kafkaesque labyrinth of conceptual confusion, intellectual dishonesty and corrupt self-interest on the part of the APA and the drug pushers that it really ought to be trashed. Regrettably, Rosenhan's hydra still has many heads.

Adaptive Failure of the PD Individual

Among the many things I find to be problematic about the proposed changes to diagnosing Personality Disorders is the concept of "adaptive failure."

Essentially, if someone doesn't "fit in" to the expectations of society and its cultural norms, this individual can be diagnosed with a personality disorder. This inability to "fit in" is the result of an "adaptive" failure on the individual's part.

There doesn't seem to be any real acknowledgment on the APAs part of long lasting effects of childhood trauma on the development of the person. Or on the fact that if you grow up in a chaotic environment, you were never afforded the opportunity to learn healthy coping methods and social skills.

I suppose it is easier to label the client as a failure, rather than look at the systemic problem of the family unit. Or acknowledge that men are typically diagnosed with PTSD (not their fault) and women are diagnosed with BPD (our fault.)

I also take issue with this idea of having to fit into a group in order to be considered free of a personality disorder.

Culture norms vary from community to community, even within the United States. What is acceptable in one area, may be considered abnormal in another.

Same sex attraction doesn't fit in to expectations and norms of many religious communities: Mormon, Muslim, Orthodox Judaism, Conservative Christianity. If you are gay in Mormon dominated Salt Lake City, does it mean you have a personality disorder because you don't fit into the norms of your culture and society? Does it mean that you have failed to adapt because you can't change your sexual orientation and corresponding behaviors?

If this person decides to move to a more liberal area where same sex attraction and behaviors are acceptable, and even considered normative, then would they cease to have a personality disorder?

This may sound hypothetical...but there are many faith based therapists diagnosing and treating clients. It would be very easy for some of them to start using the DSM 5 descriptions to label gay and lesbian peoples with mental illnesses.

This is ridiculous! No

This is ridiculous! No clinican will be able to diagnose a personaolity disorder aginst this criteria unless s/he has multiple sessions with the client.

What kind of quack would

What kind of quack would diagnose something as devastating and complex as a personality disorder in the first session anyway?

diagnosis is not that simple.

not adapting is a great description of BPD. as a person who grew up with a mother who I believe is BPD I would just like to say that this is not referring to sexual orientation. and that is not the only diagnostic criteria.

the kind of adapting that my mother struggles with are in close relationships. she thinks everyone else is responsible for her mean words.She blames everyone else for her actions. and even though it destroys her intimacy with others she persists. and claims people just take everything she does the "wrong" way.

one "mal-adaptive" behavior does not make for a diagnosis. you have to have many destructive traits.

also her life has not been significantly traumatic and the rest of her family is perfectly normal. so this is NOT just a trauma based disorder. the grouping of behaviors is not a coincidence and catch all the behaviors exist together in MANY people. BPD and PTSD are VERY different.

without BPD being defined my childhood makes no sense.

without experiencing it you can't understand how right this description is.

I think the stigma our society has against mental health issues is not the mental health field's fault. a diagnosis is an important part of treatment.

reply to anon. re: mother

While no one would argue that you have a closer insight into your mother's behavior than an objective 3rd party, is it also possible that your perceptions of her are skewed by your relationship with her? It worries me that the information so easily available on the internet has turned everyone into clinicians or, in our state, psychiatrists-- the only people who have earned a living assessing and diagnosing. I would think there is some kind of ethical criterion for assessing & diagnosing relatives-- does a surgeon operate on family?

My point is, as long as anyone whose profession is NOT psychiatry/assessing and treating mental illness, is able to believe s/he is qualified to assess/diagnose, actual diagnoses may lose value and credibility, even when given by a qualified professional.

It's my understanding that the entire DSM has been created using judgment-- whether that judgment comes from lay or professional opinion, it is still that: judgment and/or opinion. How many lives have been negatively altered by using psychology as a mechanism to process personal criteria regarding the person being assessed? Is calling someone with whom you are in a relationship BPD the new trump card?

Mum with BPL no childhood trauma

I don't think you can TELL, from the outside, whether someone else's childhood was idyllic or severely traumatizing.

Even in DID, the shattered person's psyche is said to govern itself with an alter theorists label "the apparently normal part of the person (ANP)."

Some severely traumatized and traumatizing families have nothing BUT the capacity to project that everyone is just so NORMAL.

This is one of the most brutal aspects of surviving drastic trauma IN such a family.

Everyone may be shattered and functioning for all they're worth, or it can all be dumped on a scapegoat and disowned.

Sometimes this is all blatant but more often there is huge effort to convey the lovely normality everyone craves all the more when it's fictitious.

The apparition of normalcy can protect the severely traumatized individual from being spotted and finished off by other, extrafamilial predators. It's worth its weight in gold in a world like ours.

Relative - Absolute

I used to be an electronics engineer.

I ask: "What is the voltage on that wire?"

The answer to that depends upon what "zero" reference I use.

Voltages are generally relative to a reference voltage which need not necessarily be a true and absolute zero.

So with personality: before defining what is wrong, you must find some absolute empirical and scientific way to define what the reference personality is. Since this strikes me as impossible in the present state of knowledge, there is no way to define a wrong personality.

The definitions in the DSM IV and DSM V are both plainly and clearly politically defined. One would have to be intellectually blind not to see that. The very definitions themselves are relative to the person's culture; that makes the definition inextricably political.

It has been said that you cannot judge one mentality from the standpoint of another. Evans-Pritchard, the anthropologist, remarked of the Azande Tribesman of West Africa that he is so wrapped up in his view of life that he cannot think his thought is wrong.

Americans tend to think that what a group of muslims did on the 11th of September, 2001 was wrong. Perhaps muslims don't think it was wrong. On the other hand, most americans perhaps think it is fine to go over there with weapons and kill large numbers of muslims. And perhaps large numbers of muslims think that what america is doing in the middle-east is wrong. You cannot judge one mentality from the standpoint of another.

As Fromm (1955) pointed out:

It is naively assumed that the fact that the majority of people share certain ideas or feelings proves the validity of these ideas and feelings. Nothing is further from the truth... Just as there is a 'folie a deux' there is a 'folie a millions.' The fact that millions of people share the same vices does not make these vices virtues, the fact that they share so many errors does not make the errors to be truths, and the fact that millions of people share the same form of mental pathology does not make these people sane.

(Fromm, The Sane Society, Routledge, 1955, pp.14-15)

A few hundred years ago we were burning witches; many people thought that was right and that witches really did exist. Can you be sure that you are right this time around? The prevailing culture is no valid scientific frame of reference.

Bert.

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Jared DeFife, Ph.D., is a clinical psychologist and Assistant Professor of Psychiatry and Behavioral Sciences at the Emory University School of Medicine."

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